Cumberland county schools asthma medication plan rev. Here is a sample asthma action plan you can use for a child in preschool, day care, etc child care asthma allergy action plan. North carolina advanced medical home amh program data strategy in support of care management, october 4, 2018 nc dhhs, becoming certified as an advanced medical home. The percentage of adults with asthma who reported fair or poor health ranged from 22. Asthma action plan this information is for general purposes and is not intended to replace the advice of a qualified health professional. Exercise smoke, strong odors or spray mold colds respiratory infections chalk dustdust carpet pollen change in temperature animals dust mites tobacco smoke cockroaches. Get to know this document, the cornerstone of personalized treatment for anyone with a food allergy. The guide was designed to provide useful asthma related information to all populations affected by asthma in north carolina. Before taking this form to your health care provider, complete the top left section with. While north carolina no longer has a cdcfunded asthma control program, content experts in the nc division of public health work with the asthma alliance of north carolina to reduce the burden of asthma upon the citizens of our state by. It is important make an asthma action plan that works well for you. Put a check next to the triggers that you know make your asthma worse and ask your doctor to help you find out if you have other triggers as well. Approved by north carolina department of public instruction and department of health and human services.
Sandra wilson et als better outcomes of asthma trial boat. Download the asthma action plan to your computer in your desired language. Nashrocky mount public schools asthma emergency action plan. For school use only 704 4322079 school health date receivedreceivers signature. An asthma action plan aap is a written plan of action that uses 3 stoplight zones greenyellow red to help decide what treatment relating to symptoms or peak flow results is recommended to get and keep asthma under good control. To link to the entire object, paste this link in email, im or document to embed the entire object, paste this html in website to link to this page, paste this link in email, im or document to embed this page, paste this html in website. Sandra wilson et als better outcomes of asthma trial. Medical action plan asthma consult with a child care health. It is a simple plan that describes how to achieve long term control and what to do when asthma symptoms arises. They comprise of either 3 or 4 stages depending on patient and health professionals. Asthma action plans may be based on symptoms with or without peak flow measurements. Everyone with asthma needs his or her own asthma action plan.
Health care professionals certification i certify that i performed, on the student named above, a health assessment in accordance with g. North carolina asthma plan at all stages of implementation and help us evaluate the impact of the north carolina asthma plan. Introduction to advanced medical homes north carolina. This brochure is a asthma selfmanagement action plan for adults to be completed by doctors together with their patients with asthma.
Tracking asthma related disparities and key health outcomes through a statewide asthma surveillance system. Asthma action plans are written documents developed by you and your health care provider, listing customized steps to prevent and handle an asthma episode. Nashrocky mount public schools student health servicesstudent health services nashrocky mount public schools asthma emergency action plan medication authorization form. Check out our new and improved asthma resource guide pdf, 5. The above named person is a patient currently under my medical care. Asthma and allergy foundation of america 1235 south clark street suite 305, arlington, va 22202 phone. An asthma action plan also called a management plan is a written plan that you develop with your doctor to help control your asthma. Work with your health care provider to create a plan that works for you. The card has sections for information about a medication plan and a list of your childs signs and symptoms.
Name asthma action plan, for children 6 years or older. Your goal is to prevent and control your asthma attacks. Connecticut department of health asthma action plans in pdf and word. If your child has asthma, his or her airways can become sore, swollen, and extrasensitive to irritants and allergens. Follow the yellow and red zone plans for rescue medicines according to asthma symptoms. Using a written asthma action plan makes it easier for you to measure whether your asthma is under control and it lets you know exactly what. Students date of birth date approvednurses signature. Select the one that is best for you, print a copy and fill in the information requested. Consult with a child care health consultant about this plan. If student stays in red zone, begin emergency plan. Be sure to include the three zones created by the national institutes of healthexternal icon in your plan. National asthma control initiative priority message. January 2016rev north carolina health assessment transmittal form. Apr, 2020 everyone with asthma needs his or her own asthma action plan.
Asthma information for medical professionals nc thoracic. Apr 03, 2020 while north carolina no longer has a cdcfunded asthma control program, content experts in the nc division of public health work with the asthma alliance of north carolina to reduce the burden of asthma upon the citizens of our state by. Asthma action plan community care of north carolina. Adapted from finger lakes asthma action plan and nhlbi revised 10.
Work with your health care provider to create a plan for your child. Intermittent mild persistent moderate persistent severe persistent heshe has had many or severe asthma attacksexacerbations school staff. Asthma action plan provider instructions at initial presentation, determine the level of asthma severity level of severity is determined by both impairment and risk and is assigned to the most severe category in which any feature occurs. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. North carolina health assessment transmittal form this form and the information on this form will be maintained on file in the school attended by the student named herein and is confidential and not a public record. North carolina asthma plan 202018 state publications ii. A written asthma action plan, developed jointly by the health care provider and the patient, will help the patient manage his or her asthma.
This could include teachers, school nurses, and after school care staff. Asthma action plan library national asthma council australia. Nc thoracic society offers many resources for pulmonologist or allergy specialists from medical professionals trained in the area of allergies. Asthma action plan name school dob health care provider providers phone parentresponsible person parents phone additional emergency contact contact phone asthma severity see reverse side asthma triggers identified things that make your asthma worse.
An asthma action plan aap is a written plan of action that uses 3 stoplight zones greenyellow red to help decide what treatment relating to symptoms or peak flow results is recommended to. The asthma action plan aap lists all medications with instructions on when they should be taken. Cms school web sites blythe elementary nurses corner. If you are interested in talking with our certified pediatric asthma educators to learn how to better control your childs asthma, please call the pediatric asthma program of cape fear valley at 910 6153185 to make an appointment. Cdcs national asthma control program nacp was created in 1999 to help the millions of people with asthma in the united states gain control over their disease. Asthma getting worse student needs rescue medication. Danger take these medicines and call your doctor now. Asthma action plans asthma initiative of michigan aim. It also has steps on how to handle asthma and allergy emergencies.
A manual for primary care providers, august 28, 2018 nc dhhs, data strategy to support the advanced medical home program in north carolina, july 20, 2018. You and your hcp will write an action plan that you will follow to treat your symptoms and improve your breathing. There are many different asthma action plan formats. Green zone doing well breathing is good no coughing, wheezing, chest tightness, or shortness of breath during the day or night, and able to do usual activities work, play, and exercise, and peak flow is more than. This is the general assembly of north carolina s house bill which outlines the changes to the nc public schools health assessment. Then decide with your doctor what steps you will take. Asthma action plans also tell school and other caregivers about your childs asthma. Due to a medical diagnosis of asthma, the medication listed below needs to be given during the regular school day according to the following protocol. Every person living with asthma should have an asthma action plan. Asthma action plans respiratory health association. Excessive or prolonged coughing difficulty breathing wheezing highpitched noise heard with breathing sensation of chest tightness or pain. Asthma action planmedication authorization form charlotte. Once the process is complete, most ehr systems will allow you to import the asthma action plan into a patients chart within the ehr. One way of engaging our stakeholders in evaluation of the north carolina asthma plan will be to devote one of the aanc, our largest stakeholder group and statewide coalition, each year.
Asthma action plan medication authorization form comments 1 emergency action plan. I give written authorization for the medications listed. This is the asthma action plan for dc public schools provided by the department of health. Open the asthma action plan using adobe acrobat reader. I hereby release the local school board and their agents and employees and the child care providers from any liability that may result from my child taking the. The action plan ap for beneficiaries diagnosed with asthma, unspecified disease of respiratory system, respiratory disease chronic not otherwise specifiedand chronic respiratory condition must be developed and revised with the beneficiary, legal parents, legal guardians, or foster care providers and pcpmd. Tracking asthmarelated disparities and key health outcomes through a statewide asthma surveillance system. Once you are diagnosed with asthma, it is very important that you work closely with your hcp to control your asthma. Asthma action plan national heart, lung, and blood institute.
Information for healthcare professionals nc asthma program. Asthma is a recurrent, episodic lung disease characterized by cough and wheeze. Asthma getting worse student needs rescue medication, symptoms monitored. Asthma action plan, for children 6 years or older, continued doctor doctors phone number. Information for healthcare professionals asthma resource guide. By signing below, the school nurse has your permission to share this emergency action plan with appropriate school personnel. Fayetteville, north carolina 28302 9106782300 photographicvideotaping permission. Here is a sample asthma action plan you can use for students in school.